Dental Insurance: What You Should Know

An Open Letter from Gordon J. Christensen, DDS, MSD, PhD, Provo, UT

A WORD TO THE WISE:
AN EXPLANATION OF THIRD PARTY PAYMENT FOR DENTAL CARE

In recent years there has been a significant increase in so called "managed health care" in which insurance groups make contracts with local companies to provide healthcare for specified fees and with numerous regulations and stipulations for patients. Your employer may attempt to provide insurance for you using one of these managed care programs. The following information will be helpful to you as you attempt to understand the concept and its advantages and disadvantages.

In our area, there are basically two types of managed care programs:

PPO (Professional Provider Organization)
An insurance company owning the PPO contracts with your employer to provide dental care to you. The dentists who participate in the PPO plan to treat you for significantly reduced fees. They are called "preferred providers." Only a few dentists in the community participate, usually younger dentists or mature dentists with less active practices. Dentists with active practices providing modern "standard of care" updated dentistry cannot usually participate in the PPO's because of the low fees and inability to provide services at their usually high quality level. Insurance companies providing PPO's are in "business" for one purpose--profit. They use dentists in need to staff their programs. The profit goes to the PPO owner. In today's world, with the myriad of new innovations in dentistry, it is not possible for updated practitioners to provide high level standard of care services on a continuing basis at a fee level provided by most PPO's. If you elect to join one of these plans, you can expect only maintenance level care with few innovations provided by practitioners selected by the PPO owners.

HMO (Health Maintenance Organization)
Perhaps the biggest threat in quality health care in many years of practice is the currently vogue HMO. An insurance company HMO makes a contract with your employer to provide overall health or dental care for you at an unbelievable low fee level. In our area, the fee levels of most dental HMO's will not even provide the total of two dental cleanings (scaling and polishing) per year. The dentist receives a few dollars per patient per month. Whether the patient is treated or not. Obviously, the dentist would rather not see the patient and certainly would rather not do any expensive treatment, almost all of which must be donated to you by the dentists. Generally in HMO's, the dentist can only survive financially by not treating the patients. Who profits from HMO's? Certainly not the patient or the dentist. You guessed it, the HMO owners! As in PPO's, if you elect an HMO, you have a similar group of preferred providers who participate in the plan for the same reason, usually observable by discerning patients.

Summary
I'm sorry if I have not painted a beautiful picture. Unfortunately, "managed care" is not an admirable development in American health care. It is primarily the owners of the insurance companies--not you.

Traditional "fee for service", freedom of practitioner choice, dental insurance plans provided excellent dental service for Americans for decades, and they still do so.

Additionally, a newer form of dental insurance called DIRECT REIMBURSEMENT (DR) can be obtained by your employer, in which you have complete freedom of choice about practitioners and the quality level and type of service that you want. We will be pleased to provide information on DR if you want it for your employer.

I sincerely hope that you love the American way as much as I. This is a free country. I want to choose my health practitioner based on my own criteria, and I want the very best preventative care and treatment I can get. I don't trust profit motivated companies to select my practitioners, their fees, or their services. We will be privileged to provide the best quality oral services to you available today, but I'm sorry I can't provide such care in any PPO or HMO.

Thanks for support.

Gordon J. Christensen
DDS, MSD, PhD, Prosthodontist
Diplomat American Board Of Prosthodontics (PC)

Health Care Accessibility and Quality Assurance Act (Zainyeh Bill)
This year, the Rhode Island General Assembly enacted the most comprehensive health care reform effort in the history of Rhode Island. The bill was introduced by Representative George Zainyeh (D. Warwick) and by Representatives Wasylyk, Kelley, Giniatt and Sherlock.

This new law requires that the health department enact a process for certifying health plans and standardize definitions to assist patients in making informed decisions regarding health care. Among the terms required to be standardized are: capitation, co-insurance, medical necessity, out of network, pre-existing condition, and provider network.

Your dental insurance or benefit plans must disclose the following:

• Benefits of the plan.
• Restrictions or limitations on service including exclusion of categories of service by procedure, provider, or treatment modality.
• Experimental treatment restrictions.

Plans must provide written disclosure of the following:

• Enrollee's right to seek a second opinion.
• The appeals process.
• Enrollee's right to confidentiality.
• Enrollee's right to be free from discrimination.
• Plan's policy to direct enrollees to particular providers.
• Summary of prior authorization or other review requirements.
• Plan limitations such as co-pays, out-of-pocket or out-of-plan services.
• Criteria used to authorize treatment.
• Schedule of reviews and expenses including service ratios and costs.
  

The Health Department has begun a comprehensive effort to develop the rules and policies required by this act. Check back to this site for updated information, contact the Rhode Island Dental Association at (401) 732-6833.

Is Your Dental Plan Fair and Effective?
The Rhode Island Dental Association encourages all employers to provide their employees with a fair and effective dental benefit plan. This plan should:

• ensure the delivery of high quality dental care
• provide employees the right to choose their own dentist
• emphasize preventative care to reduce the need for more costly treatment later
• encourage employee participation in dental care decision-making

If you would like a free brochure with further information regarding your dental plan, please feel free to contact us at (401) 732-6833.